Strong evidence for the efficacy of dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD) has brought hope to clinicians and patients alike. By including cognitive therapy, behavioral strategies, skills training, and exposure therapy, DBT addresses more than just self-harm and suicidal behavior (Box 1).1-13 In fact, DBT’s primary interventions—such as skills training in emotion regulation and a straightforward approach to dysfunctional behaviors—could help many people.
Because DBT is so comprehensive and practical, clinicians might be tempted to refer almost anyone who seems even slightly “borderline” for DBT. But some patients—particularly those with mood and anxiety disorders—might benefit more from other treatments. To help you make appropriate evidence-based referrals for DBT and other psychological treatments, this article recommends 4 steps:
- Know what the treatment involves.
- Consider the evidence for the treatment in patients similar to yours.
- Consider why your patient—with unique characteristics and problems—would benefit from these specific interventions.
- Communicate to the patient your reasons for the referral.
DBT: First efficacious therapy for borderline personality disorder
Marsha Linehan, PhD, developed dialectical behavior therapy (DBT) in an attempt to devise an effective protocol for highly suicidal women. Over time, she realized that many of these women met criteria for borderline personality disorder (BPD), and DBT evolved to address their emotional, interpersonal, and mental health issues.1
Linehan et al2 published results from the first randomized clinical trial (RCT) of any psychological treatment for BPD. In this study, chronically parasuicidal women who met criteria for BPD received 1 year of DBT or “treatment as usual” in community settings. Those treated with DBT experienced fewer and less severe parasuicidal events, were more likely to remain in treatment, and required fewer days of inpatient care.
Findings from 9 additional RCTs have supported the efficacy of DBT for women with BPD and other populations.3 These RCTs have examined DBT (or adapted versions of DBT) for treating:
- women with BPD and substance dependence4,5
- men and women with BPD in a community setting6
- women veterans with BPD7
- non-BPD women with bulimia8 or binge-eating disorder9
- women with BPD in the Netherlands (53% of study subjects had a substance use disorder)10,11
- depressed older adults12
- suicidal women with BPD.13
Step 1. What does DBT involve?
Difficulty with emotion regulation. DBT is based on a biosocial theory of BPD.1 Within this framework, BPD is caused by the transaction (mutual interplay) of a biologically based vulnerability to emotions with an invalidating rearing environment. The patient with BPD typically experiences strong and long-lasting emotional reactions, often to seemingly small or insignificant events such as a slight look of disappointment on someone’s face or a minor daily hassle. Patients with BPD often are especially attuned to emotional reactions, particularly signs of rejection or disapproval.
Caregivers in an invalidating environment fail to provide the support a highly emotional child needs to learn to manage intense emotions. An invalidating environment:
- indiscriminately rejects the child’s communication of emotions and thoughts as invalid, independent of the validity of the child’s experience
- punishes emotional displays, then intermittently reinforces emotional escalation
- oversimplifies the ease of problem solving or coping.1
As a result, the fledgling BPD individual learns to mistrust and fear emotions and does not learn how to manage them. A patient with BPD is like a car with a powerful “emotional engine” but lacking brakes.
Team treatment. The standard DBT treatment package is an outpatient program run by a team.1 Therapists meet weekly for consultation to help them execute DBT according to the manual, prevent burn-out, and improve skills and motivation to treat patients with multiple, severe problems. The team also maintains the DBT program’s integrity and functioning and ensures that all treatment components—including individual therapy and skills training—are in place.
In individual therapy, the therapist and client collaborate to help the client reduce dysfunctional behaviors, increase motivation, and work toward goals. Because persons with BPD often present with many serious life problems, the therapist organizes session time to address 3 main priorities:
- Life-threatening behavior (intentional self-injury or imminent threat of intentional self-injury, including suicidal crises or threats, severe suicidal ideation or urges, suicide attempts, nonsuicidal self-injury or self-injury urges, or similar behaviors).
- Therapy-interfering behaviors (actions by the therapist or patient that interfere with progress, such as angry outbursts, missed sessions, or tardiness).
- Quality-of-life-interfering behavior (behaviors or problems—such as depression, eating disorders, or substance use disorders; homelessness or financial difficulties; or serious interpersonal discord—that make it hard for the patient to establish a reasonable quality of life).